Faculty of Health Studies

Richmond Road | Bradford | West Yorkshire | BD7 1DP | UK

Tel +44 (0)1274 236088

Email

RETURN TO PRACTICE FOR HEALTHCARE PROFESSIONALS

Personal information (please PRINT and do not write in the shaded boxes)

Title and Full name / Date of birth
Address / Contact phone numbers
Home:
Mobile:
Other:
Email address / Professional Qualification to be updated
National Insurance No / HCPC/NMC/UKCC pin number (print clearly).
Date of first entry to live in the UK / Previous Surname (if applicable)
Country of Birth / Area of Permanent Residence

Professional and academic qualifications

Professional qualifications / Year obtained
Academic qualifications and other relevant short courses etc (eg ENB 998). Please state credits and level of study. (do not include school qualifications) / Year obtained
Evidence of recent study/personal development / Year obtained

NMC registration/Professional registration

Do you have current registration with the NMC/HCPC? / When did/does this expire:
YES / NO / Month: Year:
Have you ever been subject to a Fitness to Practice hearing at the NMC/UKCC/HPC or had your registration removed, suspended or had conditions imposed?
YES* / NO
*If yes, please provide full details separately including a copy of all conditions/decisions.
If you are a non-native English speaker, do you have evidence of meeting the standard NHS English language requirements (e.g. IELTS at 7)?
YES / NO*
*If no, please note you will not be accepted unless you meet these requirements

Most recent practice experience

When did you last practise using your professional qualifications?
Month: Year:
When did you last practise in the professional area that you want to return to?

Health professional posts held

Please list your recent health professional posts starting with the most recent. Please state the nature of work – e.g. staff nurse, grade/band and Trust/country of work. / Dates of employment

Other career information

Have you ever been subject to disciplinary proceedings, suspended from work or had your contract terminated due to misconduct?
YES / NO
*If yes, please provide full details on a separate page.
Please provide any other relevant information that may assist us in making a decision about your learning needs. For example, it may be useful to comment on what you have been doing when not practicing as a nurse (e.g. caring responsibilities, voluntary work. working overseas doing VSO, working as a health care assistant, etc).
SPECIAL NEEDS OR SUPPORT REQUIRED because you have a disability or medical condition
Please let us know why you want to return to practice, and why your registration has lapsed.

References

Section 1 and 2 to be completed by the applicant. We require a reference from your most recent place of employment and an academic reference. Please complete both sections with up to date telephone numbers and email addressesandattach referencesor email references to . Students cannot start the course until two references have been received. Preferably we require an employment and an academic reference. Should you struggle to find a 2nd referee we will accept a character reference from a professional person.

Name of applicant (block capitals or type) ______

1 EMPLOYMENT REFERENCE / 2 ACADEMIC REFERENCE
Name of first referee / Name of second referee
Post/Occupation/Relationship / Post/Occupation/Relationship
Address / Address

Tel: Fax: /
Tel: Fax:
Email: / Email:
Reference
SIGNED …………………………………………………………………….. DATE ……………………………………………………………….
Position …………………………………………………………………….

Clinical Placement

Are you seeking a placement in the acute or primary care setting? (please tick)
[ ] acute [ ] primary care
What specific practice area are you seeking? Examples include: medical ward, surgical ward, A&E, practice nursing, community children’s team etc.
Do you have a specific reason for wanting this placement area? e.g. you may prefer a placement in A&E as that is where you have 10 years experience and want to return to.
Do you have a preferred Trust? If so, please indicate.
CONFIRMATION OF FUNDING
To be completed by the Applicant - please tick as appropriate.
  • I am applying for an NHS funded place only
  • I am applying for an NHS funded but may consider self funding
  • I will be self funding (Outside Yorkshire & Humber LETB/HEYH)
  • My prospective employer will provide funding (please enclose a confirmation letter
from employer for invoicing purposes).
Costs / Please indicate
if placement is paying
Course Fees / tba
Placement Fees for 150 hours
Subject to additional charge for extra hours / tba
DBS check / £44
Initial Occupational Health Check / tba
Vaccination Assessment
Blood tests, etc
Additional charges for requirements / tba
Uniform / tba
Other costs / tba

Do you have any criminal convictions?

Yes / No
DECLARATION
DECLARATION: I confirm that the information given on this form is true, complete and accurate and no information requested or other material information has been omitted.
Applicant’s Signature …………………………………...... …………… Date ………………………………...... ………………….

REMEMBER TO KEEP A COPY OF YOUR APPLICATION FORM

Equal Opportunity Monitoring

The University of Bradford is committed to providing equal opportunity in application for employment and courses.

So that we can successfully achieve this aim, we need to ensure that every applicant completes this form so that we can monitor the effectiveness of our efforts.

The information provided will be kept strictly confidential.

POST OR COURSE APPLIED FOR:

PERSONAL DETAILS

SURNAME: FORENAMES:

HOME ADDRESS: (STATE ADDRESS FOR FURTHER COMMUNICATION IF DIFFERENT FROM HOME ADDRESS)

TELEPHONE NUMBERS: (PLEASE GIVE STD CODE FOR BOTH NUMBERS)

WORK:EXT:

HOME:

1. AGE4. ETHNIC CLASSIFICATION

Date of Birth:Age:Please tick as appropriate.

2. GENDER – Please tick appropriate box

White

British

FemaleMaleIrish

Other white background

Designation: MR/MRS/MISS/OTHER (Please State)

Black or Black British

3. DISABILITY – Please tick appropriate boxCaribbean

Are you a registered disabled person?African

YesNoOther black background

If yes, please give RDP card number and disability type.

Disabled Persons should note that a disability does not Asian or Asian British

preclude full consideration for employment with this Authority.Indian
Pakistani

Bangladeshi

Card Number……………………Disability Type………………Chinese

Other Asian background

THANK YOU FOR YOUR CO-OPERATION IN COMPLETING THIS SECTION. THE INFORMATION YOU HAVE

PROVIDED WILL NOT BE USED AS PART OF THE SELECTION PROCESS.

SIGNED:DATE:

Apr2017

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